does cesarean section prevents from pelvic floor disorders ? xavier deffieux (md, phd) gynecologic...
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Does cesarean section prevents from pelvic floor disorders ?
Xavier Deffieux (MD, PhD)
Gynecologic Surgery, Antoine Beclere Hospital, Clamart
University of Paris (France)
Tehrān, 2010
Does cesarean section prevents from pelvic floor disorders ?
China 2010 50%
India 18%
WHO (World Health Organization) “A C-section > 15% indicates that too many unnecessary C-sections are being performed”
Does cesarean section prevents from pelvic floor disorders ?
China 2010 50%
India 18%
Caesarean section raises the risk of complications for the mother
The cost of C-section is higher than natural birth
Does cesarean section prevents from pelvic floor disorders ?
Why so many elective C sections in the world ?
China 2010 50%
India 18%
When asked why women prefer C-section
… almost all recounted problems with :
- fetal distress and mortality
- excessive pain
- trauma to the vagina and potential pelvic floor
disorders
(urinary incontinence, fecal incontinence,
dyspareunia…)
It is important for every woman to understand what she can do to
protect her pelvic floor and avoid pelvic floor disorders
Informed consent is required before choice of delivery mode
Obstetricians and gynecologists must inform women concerning
this point
Does cesarean section prevents from pelvic floor disorders ?
Thus…the question is
« Does caesarean section prevents from pelvic floor
disorders ? »
Urinary and fecal incontinence, POP, sexual dysfunction
Hypothesis :
- Vaginal delivery is the etiology of pelvic floor dysfunction
- Caesarean section (Cs) avoid vaginal delivery
- Conclusion : Cs prevents from pelvic floor dysfunction
First point…
Vaginal delivery is not the unique etiology of pelvic floor
dysfunction
BMI > 30 g/m2 = risk factor of urinary incontinence at long term
follow-up [Fritel,
BJOG, 2005]
Does cesarean section prevents from pelvic floor disorders ?
Does caesarean section prevents
from pelvic organ prolapse and sexual
dysfunction ?
Does cesarean section prevents from pelvic floor disorders ?
Does C-section prevents from POP surgery ?
Case controls study (7556 primiparous women)Case : women who have undergone POP surgeryControls : women who did not
Does cesarean section prevents from pelvic floor disorders ?
Does C-section prevents from sexual dysfunction ?
[Klein, J Obstet Gyaecol Can, 2005]
Prospective cohort study
C-section (n=135) vaginal delivery (n=864)
At 3 months follow-up following delivery
Unhappy with sexual relations :
- 54% following C-section
- 70% following vaginal delivery p<0.05
…however, no difference in dyspareunia rates(31% vs
31%)
Does cesarean section prevents from pelvic floor disorders ?
Does cesarean section prevents from pelvic floor disorders ?
Randomized controlled
trial [Hannah, Am J Obstet Gynecol, 2004]
Does C-section prevents from sexual
dysfunction ?
Cochrane Database
Meta-analysis
Elective C-section vs vaginal delivery
3 studies (n=2396)
At 3 months post-partumPerineal pain RR 0.32 [95% CI 0.1-0.5]
**Dyspareunia RR 0.91 [95% CI 0.7-1.1] NS
At 2 years post-partumSexual dysfunction RR 0.95 [95% CI 0.6-1.4]
NSPerineal pain RR 0.65 [95% CI 0.3-1.1] NSUnhappiness with sex RR 0.87 [95% CI 0.5-1.5]
NS
Does cesarean section prevents from pelvic floor disorders ?
Does caesarean section decreases the risk of urinary incontinence ?
Does cesarean section prevents from pelvic floor disorders ?
Caesarean section is unable to prevent all urinary incontinence because vaginal delivery
is not the only etiology of urinary incontinence
Does cesarean section prevents from pelvic floor disorders ?
Deffieux et al, 2010
Pregnancy itself plays a major role
12 wg 28 wg 36 wg 3 M PP
Pre
vale
nce
of
uri
nary
sym
tpom
s
USI UUI
Prospective study
363 primiparous women
Does cesarean section prevents from pelvic floor disorders ?
No difference
Does cesarean section prevents from pelvic floor disorders ?
Randomized controlled
trial [Hannah, Am J Obstet Gynecol, 2004]
Mid-urethral slings (TVT) and pregnancy
No randomized controlled trial
Cases seriesLiterature review : 29 case reports
Recurrence rate of urinary incontinence
- 3 (21 %) following C section
- 4 (26 %) following vaginal delivery …no
difference
C-section is not recommended in pregnant women with TVT
Does cesarean section prevents from pelvic floor disorders ?
Does caesarean section decreases the risk
of fecal incontinence ?
Does cesarean section prevents from pelvic floor disorders ?
Does cesarean section prevents from pelvic floor disorders ?
Loss of bowel control can be devastating
External anal sphincter injury (anal sphincter tear)
Does cesarean section prevents from pelvic floor disorders ?
Anal sphincter injury during vaginal delivery
Sultan et al NEJM 1993
Does caesarean section decreases the risk of fecal incontinence ?
Prospective study (nulliparous women)[Chaliha, Am J Obstet Gynecol, 2001]
Fecal incontinence before pregnancy 2 %Fecal incontinence during pregnancy 15 %
Among women presenting with fecal incontinence
… 45% do not present any anal sphincter injury
Does cesarean section prevents from pelvic floor disorders ?
PRIMA study 1219 primiparous women
Faltain et al. Obstet Gynecol 2005
0/I II III/IV CS N=313
N=671 N=81 N=154
Fecal incontinence 8% 15% 19% 8% Urinary incontinence 10% 12% 12% 5% Perineal pain 4% 7% 7% 1% Dyspareunia 27% 41% 54% 29%
Ana
l sph
inct
er te
ar
Cae
sare
an s
ecti
on
Vaginal delivery
Does cesarean section prevents from pelvic floor disorders ?
The prevalence of fecal incontinence is not different
following normal vaginal delivery and C-section
Does cesarean section prevents from pelvic floor disorders ?
100% cesarean sections: a solution ?
0
20
40
60
80
100
120
25% CS 100% CS
sphincter tear andincontinence
no sphincter tear andincontinence
sphincter tear noincontinence
no sphincter tear noincontinence
250 C-section deliveries should be performed
…to prevent one case of fecal incontinence related to anal sphincter injury
9.4% 9.0%
Does cesarean section prevents from pelvic floor disorders ?
Randomized controlled
trial [Hannah, Am J Obstet Gynecol, 2004]
Does caesarean section decreases the risk of fecal incontinence ?
Cochrane Database
Meta-analyse
Elective C-section vs VB
3 studies(n=2396)
3 months follow-up afterdelivery
Fecal incontinence RR 0.54 [95% CI 0.1-1.6]
NS
2 years follow-up
Fecal incontinence RR 1.11 [95% CI 0.4-2.5]
NS
Does cesarean section prevents from pelvic floor disorders ?
Conclusion
Elective C-section (with no trial of labour) is associated
with a lower prevalence of post-partum urinary
incontinence (at 3 months FU)
However…
C-section do not prevents from long term urinary or fecal
incontinence
C-section do not prevents from long term sexual disorders
Does cesarean section prevents from pelvic floor disorders ?
Conclusion
Scientific data is insufficient to justify an elective
cesarean section in order to avoid pelvic floor
symptoms
Does cesarean section prevents from pelvic floor disorders ?